Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
PATIENT INTAKE FORM - ADULT
NAME: ________________________________________________________________
DATE OF BIRTH (DD/MM/YEAR): ___/____/_______ AGE: _______ MALE [ ] FEMALE [ ]
COMPLETE MAILING ADDRESS: _________________________________________
_______________________________________________________________________
TELEPHONE (home): ________________
(work): _______________
Email address: ________________________________________________________
Would you like to receive Naturopathic Newsletters by email? Y or N
EMERGENCY CONTACT PERSON: ______________________________________
RELATION: ______________________ PHONE: ______________________________
MARITAL STATUS: _______________________
HEIGHT: __________ WEIGHT: __________
OCCUPATION: ________________________________________________________
EMPLOYER: ___________________________________ # OF YEARS: ___________
JOB SATISFACTION: (10 = highest) 1 2 3 4 5 6 7 8 9 10
FAMILY DOCTOR: ______________________________________________________
Date of last physical exam:__________________________
Are you under the care of any specialists or alternative health practitioners?
____________________________________________________________________________________________
____________________________________________________________________________________________
Other Naturopathic Doctors you have consulted: ____________________________________________________
PLEASE STATE WHY YOU HAVE CHOSEN NATUROPATHIC MEDICINE:
____________________________________________________________________________________________
____________________________________________________________________________________________
REFERRED TO US BY: __________________________________________________
CHIEF HEALTH CONCERNS (IN ORDER OF IMPORTANCE):
Complaint
Since
Possible Cause(s)
CAN YOU TRACE THE ORIGIN OF THE PRESENT ILLNESS TO ANY PARTICULAR CIRCUMSTANCE,
ACCIDENT, ILLNESS, INCIDENT, MENTAL UPSET, OR STRESS IN YOUR LIFE? EXPLAIN.
____________________________________________________________________________________________
____________________________________________________________________________________________
1
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
IN REGARDS TO YOUR CHIEF COMPLAINT, WHAT TREATMENTS, REGIMES, DIETS, THERAPIES, IF
ANY, HAVE BROUGHT REAL IMPROVEMENT OR RELIEF?
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list all your SUPPLEMENTS, HEALTH PRODUCTS, AND PRESCRIPTION DRUGS:
**Please bring medications & supplements to your first appointment**
Medication/Supplement
Dosage
Since
Adverse Effects
List all surgeries you have had:
Procedure
Year
Complications
List any major injuries you have sustained:
Injury
Year
Long term effects
Please indicate any medical diagnoses you currently (“C”) have or have had in the past (“P”):
Influenza
Kidney disease
Multiple sclerosis
Strep Throat
Autoimmune Disease
Allergies
Mononucleosis
Arthritis
Skin concerns (acne, eczema, etc)
Epilepsy
Hyper- or Hypothyroidism
Asthma
High Blood Pressure
STI
Depression
Stroke
Yeast infections
Anxiety
Diabetes
High Cholesterol
Cancer
ADHD
Other:
Have you had any adverse effects from a vaccination? Yes/No
If Yes, Which one(s):___________________________________________________________
Do you have a job or hobby that increases your exposure to toxic chemicals, solvents, sprays, pesticides,
herbicides, heavy metals (lead, mercury, cadmium, arsenic, etc), or have you had a past exposure (living on farm,
etc) Yes/No
2
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
How would you describe the general state of your health?
_____Excellent
_____Average
_____Good
_____Fair
_____Poor
Diet
How many meals do your generally eat each day? ______ Who cooks and prepares your food? ______________
List the primary foods included in your diet for:
Breakfast: _________________________________________________________________________________
Lunch: ____________________________________________________________________________________
Dinner: ___________________________________________________________________________________
Snacks: ___________________________________________________________________________________
Beverages: ________________________________________________________________________________
List the foods you exclude from your diet: _______________________________________________________
Why are these foods excluded? ________________________________________________________________
List any of the foods that you crave (eg: chocolate, sweets, salty, sour, breads, rich/fatty or spicy
foods): ___________________________________________________________________________________
_________________________________________________________________________________________
Have you had a bad reaction to any foods?_______________________________________________________
Do you have any allergies? Y / N Please List: ____________________________________________________
Do you have any food intolerances? Y / N/ Unsure Please List: ______________________________________
How much WATER do you drink each day: ________ Are you generally thirsty? Y / N
How many times do you urinate each day? _____
Do you get up in the night to urinate? Y / N
Is it ever difficult or painful to urinate? Y / N
How often do you have a bowel movement? _____
Is your stool formed or loose?
Do you see any blood in your stool? Y / N
Mucous? Y / N
Undigested Food? Y / N
Has your weight changed lately? Lost/Gained/No Change How many pounds? _____
Please check any of the following that you use (Please include what type and how much/often):
 COFFEE OR BLACK TEA
___________________________
 TOBACCO
___________________________
 SODA POP
___________________________
 LIQUOR / BEER / WINE
___________________________
 PROCESSED FOODS
___________________________
 RECREATIONAL DRUGS
___________________________
DO YOU EXERCISE ( include frequency, duration, and intensity):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
3
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
WHAT IS YOUR STRESS LEVEL (10 = HIGH STRESS)
1
2
3
4
5
6
7
8
9
10
WHAT IS THE MAIN STRESSOR? _________________________________________
Please circle the number that indicates your level of stress (0= no stress, 5= moderate stress, 10= extremely stressful)
Financial
0 1 2 3 4 5 6 7 8 9 10
Job Related
0 1 2 3 4 5 6 7 8 9 10
Relationship
0 1 2 3 4 5 6 7 8 9 10
Health
0 1 2 3 4 5 6 7 8 9 10
Family
0 1 2 3 4 5 6 7 8 9 10
Spiritual
0 1 2 3 4 5 6 7 8 9 10
Other
0 1 2 3 4 5 6 7 8 9 10
HOW MANY HOURS PER DAY DO YOU SPEND:
WORKING _____ RECREATION______
SLEEPING ______ Do you experience any difficulty with your sleep? _____ Difficulty falling asleep?______
Difficulty staying asleep? _____
Please list the 3 most significant, stressful events in your life (physical, emotional) from the most recent to the most
distant.
Are any of these situations continuing to impact your life? (Yes/No)
1. ________________________________________Date: _________
2. ________________________________________Date: _________
3. ________________________________________Date: _________
Is there anything else I need to know about you personally, about your health condition, or about the circumstances
relating to you or your condition?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Review of Systems
Please check any symptoms you are experiencing and
write P for past experience
Vitality
 Low stamina
 Low ambition
 Fatigue
 Listlessness
 Depression
 Poor sleep
 Insomnia
 Poor concentration
 Poor memory
 Anxiety
 Bad temper
 Easily stressed
 Tendency to worry
Skin
 Dryness
 Itching
 Rough
 Bumps on back of arms
 Pimples / Acne
 Boils
 Cracking
 Eczema
 Psoriasis
 Easy bruising
 Poor wound healing
Musculoskeletal
 Weakness
 Stiffness
 Aches
 Twitching
 Cramps
 Prone to sprains
 Joint pain
 Bursitis
 Arthritis
Hair
 Thin
 Dry
 Falling
 Greying
 Excess growth
Head
 Migraines
 Tension Headaches
 Head trauma
Eyes
 Dark circles under eyes
 Watering
 Burning
 Redness
 Dryness
 Itching
 Double vision
 Blurring
 Sensitive to light
 Cataracts / Glaucoma
 Failing vision
 Conjunctivitis / Styes
 Spots in front of eyes
 Colour blindness
 Discharge
Ears
 Loss of hearing
 Ringing in the ears
 Wax build-up
 Ear Pain
 Ear Infections
Nose
 Itching
 Loss of Smell
 Discharge
 Sneezing
 Sinusitis
 Polyps
 Nosebleeds
Mouth / Lips
 Cold sores
 Lips cracking
 Cankers
 Jaw clicks
 Jaw pain
 Bad breath
 Peculiar taste in mouth
5
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Teeth
 Cavities
 Loose teeth
 Dentures / Bridges
 Root canal (s)
 Sensitive to hot / cold
 Bleeding gums
 Gum disease
 Grinding teeth
Respiration
 Smoke tobacco
 Work around chemicals or fumes
 Hay fever
 Asthma
 Coughing
 Bronchitis
 Shortness of breath
 Frequent sore throats
 Frequent colds / cough
Circulation / Blood
 Cold hands / feet
 Edema (swelling)
 Varicose veins
 Low blood pressure
 High blood pressure
 Anemia
 Fainting
Cardiovascular
 Chest pain/tightness
 Heart disease
 Palpitations
 Angina
 Heart murmurs
Neurological








Seizures / convulsions
Paralysis
Muscle weakness
Numbness / tingling
Memory loss
Involuntary movement
Loss of balance
Speech problems
Fingernails
 White spots on nails
 Nails won’t grow
 Splitting
 Peeling
 Cracking
Gastrointestinal
 Heartburn
 Indigestion
 Belching
 Flatulence
 Bloating after eating
 Fatigue after eating
 Nausea / vomiting
 Ulcer
 Constipation
 Diarrhea
 Alternating diarrhea and constipation
 Hemorrhoids
 Thirsty or thirst less
Urination
 Difficult
 Increased Frequency
 Blood in urine
 Painful urination
 Night urination
 Incontinence
Family History
 Cancer
 Heart Disease
 Diabetes
 Multiple Sclerosis
 Parkinson's
 Alzheimer's
 Osteoarthritis
 Rheumatoid arthritis
 Mental Illness
 Asthma
 Allergies
 Psoriasis
 Eczema
 Alcoholism
 Glaucoma
 High Blood Pressure
 Kidney Disease
 Thyroid Disease
6
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Females
Length of cycle (number of days between the first
day of each period)
Length of flow (how many days does your period last
for)
Colour of blood
Flow: Heavy / Moderate / Light
Clots
Painful menses
Breast tenderness
Irritability / mood swings
Bloating
Cravings
Menstrual weight gain
Vaginal discharge
Ovarian cysts
Uterine fibroids
Venereal disease
Breast lumps
Diminished sex drive
Painful intercourse
Yeast infections
# Pregnancies
# Live births
Type of birth control
Menopause
Hot flashes
Night sweats
Vaginal dryness/itching
Irregular menses
Insomnia
Anxiety/panic attacks
Bloating/indigestion
Low energy
Heart palpitations
Diminished sex drive
Painful intercourse
Lightheadedness, dizziness, vertigo
Memory problems, brain fog
Mood changes, depression
Irritability/anger
Migraine headaches
New food or environmental allergies
Urinary incontinence
Vaginal or urinary tract infections
Weight gain
Males
Hernias
Testicular pain
Venereal disease
Premature ejaculation
Discharge
Vasectomy
Prostate trouble
Diminished sex drive
Night urination
7
Dr. Lynette Panych
122 3rd Ave West Cochrane
www.cochranenaturopath.ca
(P) 403.932.7775
Dr. Lynette Panych, ND
Acknowledgment and Consent For Naturopathic Medicine:
Naturopathic doctors provide primary and complementary health care by focusing on the scientific use of natural
therapies to support and stimulate healing processes. Naturopathic doctors use standard medical diagnostic tools
(physical exam, fitness testing, health history, laboratory and imaging studies, etc.) Therapies used in naturopathic
practice are:
* Botanical Medicine
* Homeopathic Medicine
* Traditional Chinese Medicine/Acupuncture
* Clinical Nutrition
* Lifestyle/Fitness Counselling
*Physical Therapeutic Procedures/Vitamin Injections
A confidential record will be kept of your health consults and will not be released without your consent or unless
directed by law. I permit Dr. Panych, ND to use her discretion in consulting with other professionals (who are also
bound by provincial privacy laws) regarding my health in order to provide me with optimal medical care. (You may
look at your file at any time and can request a copy by paying a minimal fee.)
I voluntarily consent to the diagnostic and therapeutic procedures mentioned above.
I understand that there are health risks involved with Naturopathic Medicine services and I hereby release Dr.
Lynette Panych, ND from any claims, demands and causes of action arising from my voluntary participation in
these services.
I understand that failure to follow naturopathic prescriptions could undermine the expected results. Naturopathic
Doctors reserve the right to determine which cases fall outside his/her scope of practice, in which event an
appropriate referral will be made.
I allow communication via Email as it saves resources and response times. Dr. Panych, ND makes every attempt
to prevent computer / internet criminal activity. I understand the inherent risk involved with computer and internet
use and release Dr. Panych, ND from any liability.
All fees for services and supplements are payable at the time of the appointment. There is a fee for completing
insurance forms, letter writing, and telephone consultations of greater than 5 minutes. Please give 24 hours notice
for appointment cancellations and acknowledge that failure to do so will result in a cancellation fee for the
full cost of the appointment booked.
I have read, understood, and acknowledge the above statements. I intend this consent form to cover the entire
course of treatment/training. I am free to withdraw my consent and or terminate treatment at any time.
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DATE
PRINTED NAME
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